NCLEX Prep N181
A client comes into the E.R. with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122 BPM, and a respiratory rate of 38 breaths/minute. The client's medical history included DM, HTN, and heart failure. Which of the following disorders should the nurse suspect? A. Pulmonary edema B. Pneumothorax C. Cardiac tamponade D. Pumlonary embolys
A
An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: A. Left ventricular atrophy B. Irregular heartbeats C. Peripheral vascular occlusion D. Pacemaker placement
A
Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to see evidence of the drugs desired effect? A. 5 to 10 minutes B. 30 to 60 minutes C. 2 to 4 hours D. 6 to 8 hours
A
The nurse caring for a client with dilated cardiomyopathy is scheduling a transthoracic echocardiogram, which might reveal what type of finding associated with the diagnosis? A. Decreased ejection fraction B. Decreased Heart Rate C. Presence of bundle branch block D. Asymptomatic ventricular tachycardia
A
The nurse is caring for a patient is admitted with a diagnosis of dilated cardiomyopathy. Assessment includes analysis of which laboratory results that would be used to prioritize assessment findings? A. Electrolyte panel, specifically Na B. Kidney function panel, specifically GFR, Serum Creatinine and BUN C. Liver function panel, specifically AST, ALT, and bilirubin D. WBC panel, specifically lymphocytes
A
The physician orders continuous intravenous nitroglycerin infusion for the client with MI. Essential nursing actions include which of the following? A. Obtaining an infusion pump for the medication B. Monitoring BP q4h C. Monitoring urine output hourly D. Obtaining serum potassium levels daily
A
Which of the following is the most common symptom of myocardial infarction (MI)? A. Chest pain B. Dyspnea C. Edema D. Palpitations
A
Which of the following symptoms is most commonly associated with left-sided heart failure? A. Crackles B. Arrhythmias C. Hepatic engorgement D. Hypotension
A
A client admitted with angina complains of severe chest pain and suddenly becomes unresponsive. After establishing unresponsiveness, which of the following actions should the nurse take first? A. Activate the resuscitation team B. Open the client's airway C. Check for breathing D. Check for signs of circulation
A Immediately after establishing unresponsiveness, the nurse should activate the resuscitation team. The next step is to open the airway using the head-tilt, chin-lift maneuver and check for breathing (looking, listening, and feeling for no more than 10-seconds). If the client isn't breathing, give two slow breaths using a bag mask or pocket mask. Next, check for signs of circulation by palpating the carotid pulse.
Which of the following actions is the appropriate initial response to a client coughing up pink, frothy sputum? A. Call for help B. Call the physician C. Start an I.V. line D. Suction the client
A Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Because the client is at high risk for decompensation, the nurse should call for help but not leave the room. The other three interventions would immediately follow.
Which of the following results is the primary treatment goal for angina? A. Reversal of ischemia B. Reversal of infarction C. Reduction of stress and anxiety D. Reduction of associated risk factors
A Reversal of the ischemia is the primary goal, achieved by reducing oxygen consumption and increasing oxygen supply. An infarction is permanent and can't be reversed.
Patient w/HF is constipated. What should the nurse recommend? (SATA) A. Walking B. Increase fiber C. Stool softeners D. Drink plenty of water
A, B, C
Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. A. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. B. Activity intolerance related to increased cardiac output. C. Decreased cardiac output related to structural and functional changes. D. Impaired gas exchange related to decreased sympathetic nervous system activity.
A, C HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
A client with chronic HF took cold medicine for flu. She presents with new productive cough with pink, frothy sputum and worsening crackles. What action should the nurse take first? A. Assess lung sounds B. Give bumetanide IV- push C. Notify the HCP D. Clock out for lunch
B
A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for: A. Thrombocytopenia and weight gain B. Anorexia, nausea, and visual disturbances C. Diarrhea and hypotension D. Fatigue and muscle twitching
B
A nurse is preparing to ambulate a client on the 3rd day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? A. Encourage the client to cough and deep breathe B. Premedicate the client with an analgesic C. Provide the client with a walker D. Remove telemetry equipment because it weighs down the hospital gown
B
Aspirin is administered to the client experiencing an MI because of its: A. Antipyretic action B. Antithrombotic action C. Antiplatelet action D. Analgesic action
B
Medical treatment of coronary artery disease includes which of the following procedures? A. Coronary artery bypass surgery B. Oral medication therapy C. Percutaneous transluminal coronary angioplasty
B
Stimulation of the sympathetic nervous system produces which of the following responses? A. Bradycardia B. Tachycardia C. Hypotension D. Dereased myocardial contractility
B
The emergency department (ED) nurse is assessing a client who arrived with severe retrosternal chest pain described as burning and sharp which worsens on inspiration. The health care provider diagnoses the client with acute pericarditis. Which finding is most consistent with this diagnosis? A. Wheezes B. Friction rub C. Fine Crackles D. Coarse Crackles
B
The nurse finds the apical pulse below the 5th intercostal space. The nurse suspects: A. Left atrial enlargement B. Left ventricular enlargement C. Right atrial enlargement D. Right ventricular enlargement
B
The nurse is caring for a client who has a rapid heart rate of 135 beats/minute and heart monitor reveals atrial fibrillation. Which of the following assessment findings would the nurse expect to find? A. GI distress B. Hypotension and distended neck veins C. Increased urinary output D. Hypertension and flat neck veins
B
The nurse is caring for a hospitalized client with admitting diagnosis of right-sided heart failure (HF). What assessment finding is most consistent with the client's diagnosis? A. Pulmonary edema B. Distended neck veins C. Dry Hacking cough D. Orthopnea
B
The nurse is providing education for a client diagnosed with angina pectoris. Further education is needed after the client verbalizes which statement after teaching is provided? A. I know that exercise may increase the heart's O2 demands, and may cause angina; however, moderate exercise is benficial B. Exercise must be avoided at all costs, and I will be more comfortable in my chair during the day C. I can log symptoms and activities that precipitate angina attacks D. If I experience angina, I will stop the activity and sit or lie down to reduce O2 requirements until the pain subsides
B
Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? A. Antihypertensives B. Beta-adrenergic blockers C. Calcium channel blockers D. Nitrates
B
Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet? A. Apples B. Tomato juice C. Whole wheat bread D. Beef tenderloin
B
With which of the following disorders is jugular vein distention most prominent? A. Abdominal aortic aneuryism B. HF C. MI D. Pneumothoras
B
What is the first intervention for a client experiencing MI? A. Administer morphine B. Administer oxygen C. Administer sublingual nitroglycerin D. Obtain an ECG
B Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI, but they're more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI.
A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician's office. The nurse would plan on having which of the following medications readily available for use? A. Diltiazem (Cardizem) B. Digoxin (Lanoxin) C. Propranolol (Inderal) D. Metoprolol (Lopressor)
B Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem (calcium channel blocker) and propranolol and metoprolol (beta blockers) have a negative inotropic effect and would worsen the failing heart.
Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease? A. Decrease anxiety B. Enhance myocardial oxygenation C. Administer sublingual nitroglycerin D. Educate the client about his symptoms
B Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium suffers damage. Sublingual nitroglycerin is administered to treat acute angina, but administration isn't the first priority. Although educating the client and decreasing anxiety are important in care delivery, neither are priorities when a client is compromised.
A 55-year-old client is admitted with an acute inferior-wall myocardial infarction. During the admission interview, he says he stopped taking his metoprolol (Lopressor) 5 days ago because he was feeling better. Which of the following nursing diagnoses takes priority for this client? A. Anxiety B. Ineffective tissue perfusion; cardiopulmonary C. Acute pain D. Ineffective therapeutic regimen management
B MI results from prolonged myocardial ischemia caused by reduced blood flow through the coronary arteries. Therefore, the priority nursing diagnosis for this client is Ineffective tissue perfusion (cardiopulmonary). Anxiety, acute pain, and ineffective therapeutic regimen management are appropriate but don't take priority.
The nurse is caring for a client with heart failure who is receiving a prescribed angiotensin-converting enzyme inhibitor (ACEI). The patient is asking how the drug works for heart failure. What will the nurse include in teaching the client about this medication? (Select all that apply.) A. The ACEI reduces fluid volume B. The ACEI relaxes blood vessels and lowers BP C. The ACEI reduces workload on the heart D. The ACEI decreases pulmonary venous pressure
B, C
Which food item should the HF patient avoid? (SATA) A. Chips B. Fruits C. Vegetables D. Grilled chicken & fries E. Canned beans F. Bread
B, C, F
A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg IV push. Knowing that the client also will be started on Digoxin (Lanoxin), a nurse checks the client's most recent: A. Digoxin level B. Sodium level C. Potassium level D. Creatinine level
C
Captopril may be administered to a client with HF because it acts as a: A. Vasopressor B. Volume expander C. Vasodilator D. Potassium-sparing diuretic
C
Most common complication of an MI A. Cardiogenic shock B. HF C. Arrhythmias D. Pericarditis
C
Myocardial oxygen consumption increases as which of the following parameters increase? A. Preload, afterload, and cerebral blood flow B. Preload, afterload, and renal blood flow C. Preload, afterload, contractility, and heart rate D. Preload, afterload, cerebral blood flow, and heart rate.
C
The nurse is caring for a client with mitral stenosis on the telemetry floor and notices a change on the telemetry monitor. The nurse expects which most common heart rhythm change based on the disease process? A. Ventricular fibrilation B. Sinus tachycardia C. Atrial fibrilation D. Sinus bradycardia
C
Which of the following blood tests is most indicative of cardiac damage? A. Lactate dehydrogenase B. Complete blood count (CBC) C. Troponin I D. Creatine kinase (CK)
C
Which of the following conditions is most commonly responsible for myocardial infarction? A. Aneurysm B. Heart failure C. Coronary artery thrombosis D. Renal failure
C
Which of the following symptoms might a client with right-sided heart failure exhibit? A. Adequate urine output B. Polyuria C. Oliguria D. Polydipsia
C
Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? A. Risk for infection related to stasis of alveolar secretions B. Impaired skin integrity related to pressure C. Activity intolerance related to pump failure D. Constipation related to immobility
C Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to stasis of secretions or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with HF and pulmonary edema, nor is constipation related to immobility.
A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? A. Recent URI B. Nutritional anemia C. Peptic ulcer disease D. A-Fib
C Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.
A client who had cardiac surgery 24 hours ago has a urine output averaging 19 ml/hr for 2 hours. The client received a single bolus of 500 ml of IV fluid. Urine output for the subsequent hour was 25 ml. Daily laboratory results indicate the blood urea nitrogen is 45 mg/dL and the serum creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for: A. Hypovolemia B. UTI C. Glomerulonephritis D. Acute renal failure
D
Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? A. Pericarditis B. HTN C. MI D. HF
D
In which of the following disorders would the nurse expect to assess sacral edema in a bedridden client? A. Diabetes B. Pulmonary emboli C, Renal failure D. Right-sided heart failure
D
The nurse is performing an assessment on a client with a history of cardiovascular disease, diabetes, hypertension, and hypothyroidism. The client is experiencing exhaustion with simple activities of daily living and short ambulation, and states a 5 pound weight gain over 4 days. Assessment reveals 4+ edema to lower extremities and jugular distention. The nurse will report findings to the health care provider and anticipates which medical condition? A. Acute pericarditis B. Myocardial Infarction C. Left-sided HF D. Right-sided HF
D
What is the primary reason for administering morphine to a client with an MI? A. To sedate the client B. To decrease the client's pain C. To decrease the client's anxiety D. To decrease O2 demand on the client's heart
D
Which of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility? A. Beta-adrenergic blockers B. Calcium channel blockers C. Diuretics D. Inotropic agents
D
Which of the following conditions is the predominant cause of angina? A. Increased preload B. Decreased afterload C. Coronary artery spasm D. Inadequate oxygen supply to the myocardium
D
Which of the following is a compensatory response to decreased cardiac output? A. Decreased BP B. Alteration in LOC C. Decreased BP and diuresis D. Increased BP and fluid retention
D
Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? A. Has severe chest pain B. Can identify risks factors for MI C. Agrees to participate in a cardiac rehabilitation walking program D. Can perform personal self-care activities without pain
D
Which of the following tests is used most often to diagnose angina? A. Chest x-ray B. Echocardiogram C. Cardiac catheterization D. 12-lead electrocardiogram (ECG)
D
Which of the following types of angina is most closely related with an impending MI? A. Angina decubitus B. Chronic stable angina C .Nocturnal angina D. Unstable angina
D
Which of the following blood gas abnormalities is initially most suggestive of pulmonary edema? A. Anoxia B. Hypercapnia C. Hyperoxygenation D. Hypocapnia
D In an attempt to compensate for increased work of breathing due to hyperventilation, carbon dioxide decreases, causing hypocapnea. If the condition persists, CO2 retention occurs and hypercapnia results.
The nurse coming on duty receives the report from the nurse going off duty. Which of the following clients should the on-duty nurse assess first? A. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute. B. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order. C. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin. D. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).
D The client with A-fib has the greatest potential to become unstable and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old client admitted 2-days ago with heart failure (her s/s are resolving and don't require immediate attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires time consuming supportive measures.
